Although maternal mortality in India is declining, it remains unacceptably high, according to the report Barriers to Safe Motherhood in India, released today by the New York–based Guttmacher Institute and the International Institute for Population Sciences (IIPS) in Mumbai. Maternal deaths in India, the world’s second most populous country, constitute one-quarter of all maternal deaths globally. Therefore, India’s slow pace in improving maternal health not only has serious negative consequences for Indian women and their families, it also impedes global achievement of the United Nations Millennium Development Goal to reduce maternal mortality by 75% between 1990 and 2015.

High levels of maternal mortality are especially tragic because deaths associated with pregnancy or childbirth are largely preventable. In India, hemorrhage, a condition that is exacerbated by widespread anemia among pregnant women, is the most important cause of such deaths. In a country where abortion is broadly legal, unsafe abortion remains common and contributes significantly to maternal mortality; preventing unintended pregnancy and increasing access to trained abortion providers would go a long way toward reducing maternal deaths.

Because maternal mortality is intrinsically hard to measure, estimates vary widely: The Indian government estimates that 301 maternal deaths occur per 100,000 live births, whereas the World Health Organization puts the estimate at 450. Nonetheless, available data suggest that maternal mortality is gradually decreasing. Indian women are staying in school longer than they once did, delaying marriage and increasing their use of effective contraceptives, and they increasingly want smaller families. The total fertility rate dropped from 3.4 births per woman in 1993 to 2.7 in 2006. This decline—which means lower lifetime exposure to the risks inherent in pregnancy and childbearing—appears to be an important factor in the decrease in maternal mortality.

The study, which uses data from three successive nationally representative surveys, found that the proportion of women receiving professional delivery care increased by one-third between 1993 and 2006. Unattended births remain common, however: Half of all Indian women who gave birth in 2006 did so without the assistance of a trained professional. Nearly three-fourths of women still gave birth with no medical professional in attendance in the country’s first and third most populated states (Uttar Pradesh and Bihar), even as fewer than 1% deliver without a medical professional in the small developed state of Kerala.

“There is a societal belief that pregnancy is not a medical condition; therefore, pregnant women and their families do not seek medical care during that period,” according to Usha Ram of IIPS. “That is why home deliveries are so common, particularly among poor women from scheduled castes and tribes, who have not only limited access than others to accurate information about the need for professional prenatal and delivery care, but also limited access to services.”

While the Indian government’s incentive programs are likely behind recent increases in the proportion of women receiving professional delivery care, many obstacles stand in the way of continued progress: poor health infrastructure, scarcity of specialists and emergency obstetric services, discrimination against women from scheduled castes and tribes, and cultural attitudes that do not consider professional prenatal and delivery care necessary. Eliminating these obstacles the authors conclude, will require increased government investment in the national health care system, as well as efforts to increase the status of Indian women and raise awareness of how maternal mortality can be prevented.